Payroll Deduction Authorization - TDHCA



PAYROLL DEDUCTION AUTHORIZATION

SUBRECIPIENT: Contract No:

CONTRACTOR NAME:

EMPLOYEE’s CERTIFICATION:

I, hereby authorize

(employee name) (contractor name)

to deduct $ from my paycheck.

This deduction pays for: (Mark all appropriate types)

| Loan Repayment | Retirement | Profit Sharing | Advance |

| Uniforms | 401K | Tools | Materials |

| Charitable Donations | Insurance Premiums | Savings Bonds | Union Dues |

| Other: |

When does this deduction happen? (Mark all appropriate times)

| One time only | Weekly | Monthly |    times for     weeks |

| Other: |

Employee's Name:

Address:

City: State:

Zip: Telephone Number: ( )

Employee's Signature: Date:

OWNER’s CERTIFICATION:

I, hereby certify that the voluntary deductions above

(Project Owner/ Contractor)

will not reduce the hourly rate paid to this employee below the federal minimum hourly rate of $7.25.

Employer’s Name:

Address:

City: State:

Zip: Telephone Number: ( )

Employer's Signature: Date:

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